Spinal and spinal cord 外傷科主治醫師Hsinglin

Low back pain and radiculopathy Imaging studies and further testing not helpful the first 4 weeks Imaging studies and further testing not helpful the first 4 weeks Relief of discomfort with meds and spinal manipulation Relief of discomfort with meds and spinal manipulation Bed rest beyond 4 days may be more harmful Bed rest beyond 4 days may be more harmful 89-90% low back pain improve within 1 month 89-90% low back pain improve within 1 month

80% sciatica eventually recover 80% sciatica eventually recover 1% have nerve-root symptoms 1% have nerve-root symptoms 1-3% have lumber disc herniation 1-3% have lumber disc herniation 85% no specific diagnosis made 85% no specific diagnosis made

definitions/classifications Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) Mechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joints Mechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joints

Initial assessment of patient History : History : –age, weight loss, cancer or infection, used of drug, during of S/S, trauma, cauda equina syndrome, work status PE : PE : –fever, vertebral tenderness, limited range of spinal cord Dorsiflexation of ankle and big toe – L5, 4 Dorsiflexation of ankle and big toe – L5, 4 Achilles reflex – S1 Achilles reflex – S1 Light touch Light touch SLR text SLR text

Further evaluation of patients EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeks EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeks SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathy SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathy NCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathy NCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathy

LS X-ray recommendation age >70yrs, or 70yrs, or <20 yrs systemically ill patients systemically ill patients temp. 38°C temp. 38°C History of maligancy History of maligancy Recent infection Recent infection Cauda equina syndrome Cauda equina syndrome Heavy alcohol or drug abusers Heavy alcohol or drug abusers DM DM

Immunosupressed patients (steroid) Immunosupressed patients (steroid) Recent trauma Recent trauma Recent urinary tract or spinal surgery Recent urinary tract or spinal surgery Unrelenting pain at rest Unrelenting pain at rest Persistent pain more than 4 weeks Persistent pain more than 4 weeks Unexplained weight loss Unexplained weight loss

Treatment Conservative treatment : Conservative treatment : –1.activity modification: »Bed rest : no more than 4 days »Activity modification : heavy lifting, total body vibration, asymmetric postures, sustained for long periods »Exercise : walking, bicycling, or swimming

2.analgesics : 2.analgesics : – Panadol and NSAIDs – Opioids 3.muscle relaxants : 3.muscle relaxants : –no effect 4.education: 4.education: –condition will subside 5.spinal manipulation therapy: 5.spinal manipulation therapy: –acute low back pain without radiculopathy in 1 st month, not used in severe or progressive neurologic deficit

–Epidural injection: no change in the need for surgery, short-term relief of radicular pain when control on oral medications is inadequate or not surgical candidates.

Cauda equina syndrome Midline, most common at L4-5 Midline, most common at L4-5 1.sphincter retension : 1.sphincter retension : –A. urinary retension –B. Urinary and fecal incontinence –C. Anal sphincter tone 2.saddle anesthesia 2.saddle anesthesia 3.significant motor weakness 3.significant motor weakness 4.Low back pain and sciatica 4.Low back pain and sciatica 5.Bilateral absence of achilles reflex 5.Bilateral absence of achilles reflex 6.Sexual dysfunction 6.Sexual dysfunction

Surgical treatment Patients with <4-8 weeks Patients with <4-8 weeks –A: urgent treatment (e.g. cauda equina syndrome, progressive neurologic deficit) –B: inability to control pain with medicine Patient with >4-8 weeks Patient with >4-8 weeks –Severe and disabling and not improvement with time, correlated with findings on PH and PE.

Type of surgery Lumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infection Lumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infection Instrumentation as an adjunct to fusion : increasing the fusion rate Instrumentation as an adjunct to fusion : increasing the fusion rate Pedicle screw-rod fixation : utilize following laminectomy, shorter length of fixation segment, rigid fixation of all 3 columns Pedicle screw-rod fixation : utilize following laminectomy, shorter length of fixation segment, rigid fixation of all 3 columns

Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts

Intervertebral disc herniation Lumbar disc herniation Lumbar disc herniation –Posteriorly, one side, compressing a nerve root, severe radicular pain Characteristics findings : Characteristics findings : –Symptoms start with back pain, days after weeks yeilds radicular pain with reduction of back pain –Pain relief upon flexing the knee and thigh –Position change

–Bladder symptoms : difficulty voiding, straining, or urine retention –Exacerbation with coughing, sneezing, straining at the stool »Radiculopathy : »A.pain radiating down LE »B.motor weakness »C.dermatomal sensory changes »D.reflex changes

Straight leg raising test : <60, L5 and S1 Straight leg raising test : <60, L5 and S1

Spondylosis : no-specific degenerative process of the spine Spondylosis : no-specific degenerative process of the spine Spondylolisthesis : anterior subluxation of one vertebral body on another Spondylolisthesis : anterior subluxation of one vertebral body on another –Grade 1-4 Spondylolysis : alternative term for isthmic spondylolisthesis Spondylolysis : alternative term for isthmic spondylolisthesis

Spinal stenosis Narrowing of the AP dimension of spinal canal Narrowing of the AP dimension of spinal canal In the lumbar region : neurogenic claudication In the lumbar region : neurogenic claudication In the cervical region : myelopathy and ataxia In the cervical region : myelopathy and ataxia In the spinal region : rare In the spinal region : rare

Spinal trauma Uncommon in children Uncommon in children The fatality rate is higher with pediatric spinal injuries than with adults (opposite to the situation with head injury) The fatality rate is higher with pediatric spinal injuries than with adults (opposite to the situation with head injury)

Complete lesion : Complete lesion : –no preservation of any motor or sensory function more than 3 segments below the level of the injury –Persistence of complete spinal cord injury beyond 24 hours : no distal function will recover

Incomplete lesion: Incomplete lesion: –Any residual motor or sensory function more than 3 segments below the level of the injury. –Signs of incomplete lesion : »Sensation or voluntary movement in the Legs »Sacral sparing Central cord syndrome Bown-Sequard syndrome Anterior and posterior cord syndrome

Spinal shock A. interruption of sympathetics A. interruption of sympathetics –1. Loss of vascular tone –2. Leaves parasympathetics causing bradycardia B. Loss of muscle tone result venous pooling B. Loss of muscle tone result venous pooling C. True hypovolemia C. True hypovolemia

Initial management of spinal cord injury Cause of death : aspiration and shock Cause of death : aspiration and shock SCI : SCI : –Significant trauma –Loss of consciousness –Minor trauma with spinal pain –Associated findings suggestive of SCI : »Abdominal breathing »priapism

Management in the hospital 1. Immobilization 1. Immobilization Hypotension: maintain SBP>90mmhg Hypotension: maintain SBP>90mmhg –Dopamine, careful hydration, atropine for bradycardia associated with hypotension Oxygenation Oxygenation NG tube decompression NG tube decompression Indwelling foley Indwelling foley Temperature regulation Temperature regulation

Electrolytes Electrolytes Medical management specific to spinal cord injury : Medical management specific to spinal cord injury : – methylprednisolone : given with 8 hours of injury